Sunrise Community, Inc. & Affiliates Compliance Reporting Form

 

 

           THIS SITE IS NOT A 911 OR EMERGENCY SERVICE.  Do not use this site to report events

           presenting an immediate threat to life or property.  Reports submitted through this service may

           not receive immediate response.  If you require emergency assistance, please contact your local

           authorities.

 

          This form is intended for all staff, vendors and stakeholders, to submit compliance concerns.  If you

          wish to remain anonymous, you are not required to enter personal information.  Sunrise respects

          your right to privacy, all information received will be kept confidential. 

                   

Are you a Sunrise Employee?                Yes         No

Do you wish to remain anonymous?       Yes         No

If yes, go to Section II

May we contact you for additional information?       Yes         No       

If yes, please complete the Section I

SECTION I

 

First Name

Last Name

Middle Initial

Title

Organization

Address 1

Address 2

City

State

Zip/Postal Code

Work Phone

E-mail

 

SECTION II

 

What is the nature of this concern/matter?
 

Have you discussed this concern/matter with your supervisor?       Yes       No
   

SECTION III

 

Person/Issue Being Reported
 

Name/Issue

Company Name

Location

Job Title (if applicable)

Type of Incident

Date of Incident

Time of Incident

Location of Incident

 

Incident Affected ( Check all that apply):
 

Self

Employee

Person/Consumer receiving services

Other (Please explain)

 

 

Description of Incident

 

          Compliance is conforming to established rules, regulations and policies.  It is ensuring that those

          who conduct business for or on behalf of Sunrise are demonstrating established ethical behaviors

          and upholding established standards as measured against commonly accepted rules of conduct

          for society or for a profession.  Sunrise is committed to conducting its business in accordance with

          all federal, state and local laws which govern its industry.  Sunrise can only meet this commitment

          through the diligent efforts of its employees. They must demonstrate behavior that reflects integrity,

          honesty and compliance with applicable legal and regulatory requirements.  Sunrise is committed to     

          maintaining a work environment that promotes these principles and permits its employees to perform

          their daily task in a work culture with the utmost  professionalism.

 

          The Compliance Reporting Form is one of the tools available for reporting compliance issues and

           incidents that may include: 

 

                       Conflicts of Interest

                       Embezzlement or Fraud (Including Kronos)

                       Ethical Standards Violations

                       Medical Billing Irregularities

                       Consumer Abuse

                       Consumer Privacy Rights/Other Consumer Rights (HIPAA Issues)

                       Consumer Safety

                       Safety, Health and Environmental Violations/Concerns

                       Policy Violations

                       Substance/Alcohol Abuse

                       Theft or Abuse of Sunrise  Property (Including Sharing of Passwords)

                       Threats to Property

                       Workplace Violence

 

            While it is not the intent of the Compliance Department to replace current procedures for reporting

            issues to your supervisor or other managerial authority, it is the responsibility of all employees to

            report any violation of laws or ethical standards to which Sunrise must adhere.  In no event shall

            any individual who reports a concern be subjected to any retaliation related to a report which he

            or she reasonably believed to be true and offered in good faith.